1. Default Section

* 1. Date of Application (mm/dd/yyyy)

* 3. Have you been admitted in the Teacher Education Program?

* 5. Name

* 6. Local Address(Street, City, State, Zip):

* 7. Telephone Number

* 8. Banner ID:
( Your Banner ID is located on the upper right screen when logged into Braveweb)

* 9. Date of Birth (mm/dd/yyyy)

Note: All placement correspondence is handle through the Office of University-School Programs and local education agency (LEA) personnel in accordance with policies jointly established by The University of North Carolina at Pembroke and the local school systems. Under no circumstances should you contact a superintendent, pricipal, or teacher about your prospective placement. Your unauthorized approach may jeopardize your placement in that system.
Out-of-Area Placements:
An out-of-area placement occurs when the internship is completed at a school system other than those listed in item 9. Under excepetional circumstances, a candidate mayrequest permission to complete an out-of-area placement. To be considered for such a placement, a candidate must submit acompleted Out-of-Area Plament Request Form and the supportingdocumentation as decribed on the request form to the Director of University-School Programs. Deadlines for requesting an out-of-area placement are February 15th for fall internshipand October 1st for spring internship

* 12. List the names of North Carolina schools system attended
(K-12). List dates of attendance.

* 13. Do you have any relatives who are either employed with or attend any of the schools in the systems listed in item 9?

* 14. If you answered yes to question 11, provide the information below

NOTE: In order to avoid a conflict of interest, student interns will not be placed in a school that he/she attended, in which a relative is employed, in which a relative is enrolled, or in which he/she has been employed. Exceptions will be made only under extreme circumstances and with the approval of the Director of University-School Programs.

* 15. Please list any special situations or personal conflicts that you want the Office of University-School Programs to consider.

* 16. Please answer the following questions.

  Yes No
Have you ever been convicted of a felony or crime other than minor traffic offense?
Have you entered a plea of guilty, a plea of no contest, a plea of nolo contendere, or an Alford plea, or have you received a deferred prosecution or prayer for judgment pretaining to a crimmal charge?
Do you have any crimmal charges pending against you?
If you have ever served in the military, did you receive any type of discharge other than an honorable discharge?

* 17. If you answered yes to any question in Q 14, submit the date, name of the office, the trail court including city and state, and any other pertinent information relating to the criminal activity.

* 18. I hereby affirm that the information furnished in this application is correct and grant the Director of Unversity-School Programs permission to submit copies of this application and my resume to respective school systems for the purpose of internship placement.